Provider Demographics
NPI:1215565957
Name:RED CANYON, LLC
Entity Type:Organization
Organization Name:RED CANYON, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MATT
Authorized Official - Middle Name:
Authorized Official - Last Name:ROSEWAG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:410-442-4059
Mailing Address - Street 1:21 CROSS ROADS DRIVE
Mailing Address - Street 2:SUITE 330
Mailing Address - City:QWINGS MILLS
Mailing Address - State:MD
Mailing Address - Zip Code:21117
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7402 YORK RD STE 104
Practice Address - Street 2:
Practice Address - City:TOWSON
Practice Address - State:MD
Practice Address - Zip Code:21204-7519
Practice Address - Country:US
Practice Address - Phone:410-716-0222
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-03-30
Last Update Date:2020-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No261Q00000XAmbulatory Health Care FacilitiesClinic/CenterGroup - Multi-Specialty